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LETTER TO EDITOR Table of Contents   
Year : 2009  |  Volume : 12  |  Issue : 1  |  Page : 89-91
Diagnostic fiberoptic bronchoscope aided double lumen tube insertion


Department of Anaesthesiology, Kasturba Medical College, Manipal - 576 104, Karnataka, India

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How to cite this article:
Goneppanavar U, Prabhu M, Appuswamy E, Kaur J. Diagnostic fiberoptic bronchoscope aided double lumen tube insertion. Ann Card Anaesth 2009;12:89-91

How to cite this URL:
Goneppanavar U, Prabhu M, Appuswamy E, Kaur J. Diagnostic fiberoptic bronchoscope aided double lumen tube insertion. Ann Card Anaesth [serial online] 2009 [cited 2019 Nov 18];12:89-91. Available from: http://www.annals.in/text.asp?2009/12/1/89/45025


The Editor,

The technique of double lumen tube insertion is lot more complex than conventional single lumen tube intubation due to the structural differences and the need for placement of the bronchial lumen appropriately into the correct bronchus. Though an effective method has been described for their insertion, several case reports have described the difficulties in correct placement despite the unhindered and easy passage of these tubes through the vocal cords in most cases. Fibreoptic evaluation and repositioning solves most of the problems. The diagnostic fibreoptic bronchoscope is not useful in such situations because of its larger external diameter. This case report emphasizes the utility of the diagnostic bronchoscope (in the absence of smaller diameter bronchoscopes) in situations where anatomical abnormalities of the tracheobronchial tree cause difficulty in positioning the double lumen tubes. It also highlights the importance of performing fibreoptic bronchoscopy preoperatively (under local anaesthesia) as a diagnostic tool in such patients.

Fiberoptic bronchoscopy remains the accepted standard for appropriate positioning and confirmation of double lumen tubes (DLT). Non-availability of thinner fiberoptic bronchoscope becomes a limiting factor When double lumen tubes are used because of their smaller internal diameters. [1] Conventional method of insertion is usually performed without fiberoptic confirmation at such times. We describe a case where direct evaluation of the tracheobronchial tree with a diagnostic fiberoptic bronchoscope (external diameter: 5.6 mm) helped to identify the anatomical problem and contributed to appropriate positioning of the DLT in a patient with abnormality of the tracheobronchial tree.

A 28-year-old man weighing 52 kg (height: 1.74 m) was diagnosed to have post-tubercular empyema thoracis and was scheduled for decortication of the right lung. The chest X-ray revealed right-sided pleural effusion with collapse of the underlying lung [Figure 1]. Deviation of the trachea to the right was also noted. The pleural aspirate did not reveal any bacterial growth after 72 h. Preoperative fiberoptic evaluation of the tracheobronchial tree and further radiological investigations were not done. The anaesthetic plan was to insert a left DLT in order to isolate the left lung.

After establishing standard monitoring, general anaesthesia was induced with fentanyl citrate and propofol, and neuromuscular blockade was achieved with vecuronium bromide after confirming ability to mask ventilate. Intubation was attempted with left-sided 39 F DLT (Broncho-Cath TM ; Mallinckrodt Medical Ltd., Athlone, Ireland). We followed the recommended technique of intubation by rotating the DLT 90-100 counter-clockwise once its tip crossed the vocal cords. But, clinical evaluation revealed that the DLT had been placed in the right bronchus instead of the intended left. Attempts by two different physicians also failed; these were made with the left bronchial lumen stylet left in situ and patient's head being turned to the right side until resistance to further advancement of the DLT was felt. Since we did not have an appropriate sized bronchoscope to pass in to the lumen of the DLT, rail-roading the DLT was not possible. At this stage, with the available fiberscope (5.6 mm) examination of the tracheobronchial tree was performed. Counter-clockwise rotation of the trachea with the left bronchus being located posterior to the usual location was detected [Figure 2a],[Figure 2b].

After keeping the new findings in mind, we reinserted the DLT by providing gentle counter-clockwise rotation of additional 45 (a total of 135) instead of the conventional 90. This resulted in successful left-sided endobronchial positioning of the DLT and was confirmed by clinical evaluation. The bronchial cuff had to be inflated with 1 ml of air to prevent leak suggesting that the size of the DLT was appropriate. The whole process starting from induction to successful isolation of the lungs took approximately 20 min. As we could mask ventilate adequately between the attempts with 100% oxygen and isoflurane with intermittent boluses of propofol, the patient remained well-oxygenated through out.

Surgery and intraoperative period were uneventful and the trachea extubated at the end of the surgery. Post-extubation, the patient was observed in the intensive care unit. Postoperative CXR did not reveal any complications. He was discharged from the intensive care unit after 48 h.

Patients with pulmonary pathology can have varying degrees of tracheobronchial distortion. Literature suggests that anaesthesiologists world wide have managed to appropriately position the DLT with the conventional technique or with the aid of the fiberoptic bronchoscope. [1] It is not uncommon to find significant variation in the anatomy of the tracheobronchial tree. Further variation is added by distortion related to the presence of tumour/effusion. Therefore, DLTs have been found to be associated with a low margin of safety with respect to their potential to occlude a major airway. [2]

The left-sided DLT can be malpositioned in three ways: into the right mainstem bronchus, inserted too far or not far enough into the left mainstem bronchus. [3] Double-lumen tubes are supplied with a stylet in place to help retain their shape. When the stylet was retained, the DLT was found to be in the correct bronchus and in the correct position more often than when the tracheobronchial intubation was done without a stylet. Accuracy of placement did not depend on the experience of the laryngoscopist, size of the DLT and sex or size of the patient. [4] However, in our case, despite retaining the stylet and turning the head to the right, we failed to achieve proper positioning. We believe that the empyema and collapse of the right lung may have resulted in deviation and rotation of the trachea resulting in failure to position appropriately.

The availability of fiberoptic equipment in the operating theatre promotes accurate knowledge of the anatomy of the tracheobronchial tree. Availability of a suitable sized thinner bronchoscope may have solved the issue. Despite the non-availability of suitable sized fiberscope, availability of a 5.6 mm scope helped us identify the problem. Fiberoptic evaluation has helped in identifying some congenital anomalies such as the presence of bronchus intermedius as the cause for repeated misplacement of the DLT. [5] Direct inspection of the bronchial tree with a fiberoptic bronchoscope has been proposed to ensure correct placement. [6] Our case re-emphasises the importance of direct evaluation of the tracheobronchial tree.

Other options available in such situations are use of bronchial blockers, intentional endobronchial intubation using a single lumen tube, passing appropriate size fiberscope through the bronchial lumen and inserting the fiberscope into the intended bronchus followed by railroading of the bronchial lumen accurately into the desired bronchus. [1],[7]

Preoperative diagnostic fiberoptic bronchoscopic evaluation of the tracheo-bronchial tree may help the physicians identify the anatomy and be forewarned. Procuring an appropriate sized bronchoscope (3 mm) may be advisable while performing thoracic cases using double lumen tubes.

 
   References Top

1.Wilson WC, Benumof JL. Anesthesia for thoracic surgery. In: Miller RD, ed. Miller's Anesthesia, 6 th ed. Philadelphia: Churchill Livingstone; 2005. p. 1847-939.  Back to cited text no. 1    
2.Benumof JL, Partridge BL, Salvatierra C, Keating J. Margin of safety in positioning modern double-lumen endotracheal tubes. Anesthesiology 1987;67:729-38.  Back to cited text no. 2  [PUBMED]  
3.Brodsky JB. Proper positioning of a double-lumen endobronchial tube can only be accomplished with the use of endoscopy. J Cardiothorac Vasc Anesth 1988;2:105-9.  Back to cited text no. 3    
4.Dianne L, Judith L, Tom H, Helmut U. Placement of left double-lumen endobronchial tubes with or without a stylet. Can J Anesth 1996;43:238-42.  Back to cited text no. 4    
5.Rebecca S, Mindy R, Matthew BW, Benumoff JL, James H. Bronchial trifurcation at the carina complicating use of a double-lumen tracheal tube. Anesthesiology 1994;80:1162-4.  Back to cited text no. 5    
6.Ovassapian A. Fiberoptic-aided bronchial intubation in fiberoptic airway endoscopy in anesthesia and critical care. New York: Raven Press; 1990.  Back to cited text no. 6    
7.Ip-Yaam, PC, Cheong KF, Koh KF. Placement of double-lumen endobronchial tubes. Br J Anaesth 1999;83:682-3.  Back to cited text no. 7    

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Correspondence Address:
Umesh Goneppanavar
Department of Anaesthesiology, Kasturba Medical College, Manipal-576 104, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.45025

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